After release of the contracture, one will be frequently faced with a shortage of volar skin, especially if the skin was adherent to the nodules and cords.

Forceful correction after either needle or collagenase (CCH) treatment in severe contractures often creates a skin tear, which requires several weeks of dressing, thus losing part of the benefit of these nonsurgical treatments.

Surgery allows compensating for the skin shortage either with local skin flaps in 90° contracture with supple skin or with skin grafts when the contracture is greater, and/or the volar skin is scarred. Skin grafting in this case has a double objective: replace the missing skin and protect the area against recurrence.

In extremely severe cases, two-step procedures carry the advantages of softening and enlarging the skin before fasciectomy. Primary needle fasciotomy can be helpful in extending the MP joint in combined MP and PIPj contractures. In even more complex cases, preliminary distraction with an external fixator (TEC, S Quattro, Digit Widget, etc.) and then followed by fasciectomy may lead to satisfactory correction without skin problems (Rajesh et al. 2000).

Whereas the nodules and cords in the palm are always superficially located, i.e., above the neurovascular pedicles and tendons, their patho-anatomy is complex at the digital level, with nodules and cords in different planes, including retrovascular and spiraling around the neurovascular pedicles. In the finger they are therefore much more difficult to reach with a percutaneous needle, and consequently neither needle fasciotomy nor CCH are likely to be fully effective. This is easily demonstrated in the literature: correction of the contracture is better with surgery than with the other two techniques (van Rijssen et al. 2006; Misra et al. 2007; Foucher et al. 2001). Nevertheless needle fasciotomy might be used to prepare severe cases for subsequent fasciectomy (Fig. 25.2).

Variable distribution of cords also puts the neurovascular bundle and even the tendons at risk with percutaneous techniques. Ultrasound has not proven very helpful, even with mini-probes, because of the flexed position of the joint and the possibility of isoechoic cords (Leclère et al. 2014; Uehara et al. 2013).

In severe long-standing Dupuytren contracture, the periarticular joint structures become involved in the contracting process, and the only way to release them is through surgery. Incision of the flexor sheath and of the check reins improves PIP extension in these cases. However one should not try to obtain full PIPj extension at all costs, and forceful maneuvers may be counterproductive, especially in arthritic joints, leading to a decrease of the ROM in flexion, far more impairing functionally than the lack of extension.

In long-standing flexion contracture, the central band of the extensor apparatus may attenuate. This is obviated by the tenodesis test performed at the end of the procedure: full passive flexion of the wrist fails to provide PIP joint extension (Smith and Breed 1994; Smith and Ross 1994). This needs to be addressed by central band shortening and repair (if needed) or temporary K-wire immobilization in extension, the latter being our preferred way of treatment.

Flexion contracture of the PIPj may lead to a reverse contracture of the distal interphalangeal joint (DIPj) in hyperextension. Sometimes this deformity can be treated by gentle manipulation after PIPj release, but in some cases, it requires surgical correction: release of the oblique retinacular ligament and/or distal tenotomy of the extensor apparatus (Tubiana 2000). Arthrolysis of the DIPj is rarely necessary.

Surgery of a severe contracted PIPj is not easy and requires attention to a number of details.

The skin flaps must be carefully planned to avoid skin necrosis, including wide angles, proximally based flaps, avoidance of undermining, and preventive skin grafting, when the cutaneous blood supply is too scarce. If the skin shortage is important, it is wiser to plan for skin replacement by a full thickness graft. Graft take is better over a bloodless field and a vascularized bed, therefore requiring tourniquet release and hemostasis and conservation of the flexor tendon sheath underneath the graft.

The neurovascular pedicles are particularly at risk, and the patient must be warned about the risk of finger necrosis, especially in the index and 5th finger, where one of the two collateral arteries may be extremely thin.

The postoperative regimen includes physiotherapy and splinting in all cases of severe contracture. When a skin graft has been used, this is started after graft take is ascertained. Special attention is focused on recovering early PIPj flexion.

Complications of surgery of the severely contracted PIPj include skin slough, skin necrosis, laceration of nerves and arteries, stiffness, complex regional pain syndrome, and the dreaded finger necrosis. The rate of complications after fasciectomy varies greatly in the literature, from 3.6 to 39 % (Denkler 2010). Our own series involving 155 patients lead to 14 % complications. Literature reviews seems to indicate a trend toward a reduction in the reported percentage of complications in more recent years (Table 25.1) (Denkler 2010; Becker and Davis 2010).